ID:

Name: Mohammed Jehad Amer .

Age: 5 year old male patient .
Address: Azmoot
Date of admission: 6/1/2013
Date of History taking: 6/1/2013

Informant:
His mother who seems to be reliable .

Chief Complain:
Fever and Chills for 5 days .

History of present illness:

Mohammed Jehad who is known case ( neurogenic bladder with hydronephrosis
and recurrent infection , imperforated anus and VSD with dilated cardiomyopathy )
was in his usual state of health until 5 days prior to admission when he started to
complain of fever and chills ( 39.5 measured axillary ), then the mother gave him
antipyretic and improved just for 1 hour .Then , after 1 day he complained of sever
gradual lower abdominal pain radiated to LIF .
This was associated with dysuria , dark urine and bad odor ( many dippers cause
not toiled trained cause of neurogenic bladder ) .
Also , associated with vomiting ( 5 times , moderate amount , yellow in color
) , pallor , poor apettite decrease activity ( during fever ) , frequent water intake ,
and fatigue .

,
There was history of frequent admissions for the same symptoms. .
No recent history ofURTI , .
No history of easy bruses , or eating out side
No constipation or diarrhea .

At 5/1/2013 Mohammed Jehad came to Rafedia hospital and admitted through ER

to pediatrics department.

Systemic Reviews:
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General:, no weight loss or

Skin: no rashes , no nail or hair problems
Eyes: no redness ,
ENT: no rinohrea, no snoring, no painful swallowing, no ear discharge
CVS: palpitation , SOBOE , no chest pain
Respiratory system: no SOB , no cough .
GI: mentioned
Genitourinary: mentioned
Neuromuscular: unable to upstairs alone , no irritable, no convulsions,no
ataxia , no joints swellings or pain

Past History:
1. Antenatal: Good health of mother during pregnancy, she visited pregnancy
clinics regularly, U/S done and was normal, no complications during
pregnancy
2. Neonatal: he is a product of, normal vaginal delivery GA 9 months, 3 kg
3. Postnatal: baby pink color,immediate crying , no cyanosis, no jaundice,
NICU admission for imperforated anus and hydronephrosis . for 10 days .
4. Growth and development:
Walking at one year .
He is not toilet trained.

 Speaking at 14 months
Reactive with others .
Now he is in kinderkarten but with difficulty .
5. Nutrition:
Breast fed until age of 16 months
Solid food at 6 m
Poor feeding in general
he now eating house hold food
6. Past medical hx, previous hospitalizations for high fever .
7. Past surgery : ureter reimplantation on the lift side ,, imperforated anus .
8. Drug history: aldactone , lasix , capoten , aspirin , giflix .
9. Allergy : no known allergons
10.Immunization: up to schedule , no complications .
11.No blood transfusion .

Family History:
Father with MI at age of 40 years
3 times abortion in the 1st trimester
No similar Hx in other realatives
Healthy brothers and sisters .

Social History:
His parents are cousin
job : construction labor

He lives in 5th floor, well ventilated house

he is the 5th child of 6 siblings .
no smoking
No domestic animals
moderate economic status

Physical Examination:
1. General appearance: patient looks well , sleeping on the bed , not pallor
,wet mucous membrane , not tacypnic , normal skin turgor , no cyanosis,
normal capillary refill , canula inserted into his right hand
2. Vital signs:
Temp39 C
Pulse: 100/min
RR: 25/min
Growth parameters:
Weight: 12 kg below 5th percentile
Length: 98 cm
below 5th percentile
3. ENT: ears were not examined by otoscope but by inspection there was no
discharge, no redness, and no tenderness.
4. GI system:
Inspection: abdomen destended , umbilicus not centrally, normally
inverted, fullness on lft flank , no echomosis, no pigmentations,there
was a scar in RIF vertical about 7cm , no visible masses, no dilated
veins, no jaundice
Palpation: superficial palpation revealed no tenderness, mass in lower
abdomen 5 by 4 cm mostly distended UB and mass in the lf flank
mostly enlarged kidney. Deep palpation revealed not palpable liver or
spleen .
Positive renal angle tenderness on the lift side .
Auscultation: normal bowel sound
4- geniurinary examination : revealed small penis with retractile testes .
5. Respiratory system:
Inspection: no subcostal retraction, no chest deformity, no visible
pulsation, no scars, no tracheal tug, no nasal flaring

 Palpation: trachea is centralized

Percussion: ---- Auscultation:, normal vesicular breathing sound .
6. CVS:
Inspection: no chest deformities, no visible pulsation, no scars
Palpation: no thrills, no heaves, PMI (5th intercostal space MCL)
Auscultation: tachycardia, systolic murmer, no added sounds
Pulse: 100/min regular weak volume.
Capillary refill < 2 seconds
7. Neurological examination :
Fully conscious and alert
Symmetric face
Crainial nerve ;grossly normal , no abnormality detected .
Normal tone , power
Negative signs of meningeal irritation

Summary:
Mohammed Jehad a 5 year old patient known case of neurogenic bladder sice
birth came to hospital complaining of fever and chills with lower abd. Pain for
5 days ,,,, OE ,, the abdomen is destended with distended UB

D.D:
UTI ( pyelonephritis ) .